The dog days of summer are over and the kids are back in school. That means it’s time to focus on fourth quarter (Q4) planning. For many companies, this is the most important quarter of the year: assessing how goals have been met, making final corrections and setting expectations for the following year.
Pharmaceutical companies should think outside the box and strengthen their planning efforts by including three essential trends:
Real-time pharmacy benefit information. Until recently, there was no method for prescribers to identify costs of drugs for patients — which drug is on formulary, how much insurance will cover and what, if anything, the patient might have to pay out of pocket. Now real-time pharmacy benefit information is appearing in practices via real-time pharmacy benefit check (RTPBC). RTPBC provides real-time copayment information at the point of prescribing along with prior authorization (PA) requirements and the payer’s preferred alternative drugs. As the impact on pharmaceutical brands is significant, we’re tracking RTPBC development and deployment closely. We will be updating our overview and collecting samples of electronic health record (EHR) deployment this fall.
Electronic prior authorization (ePA). Manual prior authorization (PA) for medications, devices and services is a pain point for providers, patients and plans. Now digital transformation is under way with the ability to make real-time authorization requests at the point of care. Automation reduces time to therapy and expensive overhead for pharmacies and physician practices while decreasing the need to use portals from payers and hubs. Efforts in this area are under way. (Read our article on the evolution of ePA for the details). We’re happy to provide background on recent developments.
Specialty pharmacy automation. In contrast to retail pharmacy, which is highly automated, specialty pharmacy is mired in antiquated phone, fax and paper processes. Stakeholders are interested in automating specialty pharmacy because of the growing costs and use of expensive specialty medications to treat the rapidly growing number of people with chronic diseases. These efforts also dovetail with other efforts to computerize health care and reduce physician burden. Efforts to automate specialty pharmacy continue to accelerate, with progress already being made. For example, efforts are under way to computerize enrollment and identify which new data elements useful in the enrollment process can be incorporated in the SCRIPT standard from the National Council for Prescription Drug Programs (NCPDP). These include, for example, additional patient contact and demographic information, diagnosis, lab values, height and weight.
Why are these trends important? It’s obvious that these trends are important to improve speed to therapy, reduce costs and improve quality of care. That said, there are other reasons why pharmaceutical companies should be paying attention.
Alignment with federal and state mandates. In May, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that requires plan sponsors to have real-time pharmacy benefit (RTPB) information capable of integrating with at least one prescriber’s EHR system for drugs prescribed under Medicare Part D by January 1, 2021. Shortly after this rule was finalized, CMS issued a proposed rule that would require Part D plan sponsors to support version 2017071 of NCPDP SCRIPT for ePA transactions with prescribers regarding Part D covered drugs to Part D eligible individuals – also by January 1, 2021. Other public and private payers tend to follow Medicare’s lead, which will make ePA for drugs covered under the patient’s pharmacy benefit common across the industry. In addition, states are jumping on the ePA bandwagon. Nearly half now mandate use of ePA or allow its use, often in leveraging the NCPDP SCRIPT standard. However, state requirements vary. In addition, several bills have been introduced in the House of Representatives to expand use of the RTPB information beyond Part D. One of them may gain traction this fall. Planning for and complying with legislative and regulatory changes are business imperatives.
Intense stakeholder involvement. Many trends involving health information technology (health IT) seem to run under the radar. Not so with RTPB information, ePA and specialty pharmacy automation. These trends are the focus of intense involvement by powerful stakeholder groups, whose collaborative efforts are rapidly driving changes. For example, the CARIN Alliance — a large, multistakeholder coalition — has formed a workgroup aimed at advancing the consumer-facing RTPB information. The American Medical Association (AMA) recently convened a group that led to the development of a consensus statement on improving the PA process. Participants included the AMA, American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, BlueCross BlueShield Association and Medical Group Management Association. Since its creation, more than 100 other organizations have become involved in the project. Finally, the eHealth Initiative convened a collaborative ePA project. Participants include nearly three dozen organizations representing payers, providers, government agencies and vendors. Such collaborations and initiatives — with diverse and influential members — are high-visibility drivers for change.
Payer price transparency. Price transparency at the point of care is a huge issue that is receiving national attention and considerable media coverage. It is among the priorities at the Department of Health and Human Services. Lack of stable prescription coverage, as well as unpredictable pricing and sticker shock at the pharmacy, are drivers for change. The real-time pharmacy benefit check (RTPBC) described above can help. It builds on progress to date concerning important prescription cost and coverage information available at the point of prescribing. A response to prescriber challenges with benefit information, RTPBC advances price transparency, especially when used in conjunction with ePA. This is far from a perfect solution because there isn’t a way to convey any manufacturer programs.
In addition, if patients and providers are equipped with partial coverage and cost information, prescription options can be distorted, leading to decisions that help payers but not necessarily patients.
Response planning. There are many possible action steps for companies to consider. For example, pharmaceutical companies could:
Get involved with stakeholder collaborations. Companies must understand the value and opportunity in participation and collaboration in the various stakeholder-led initiatives concerning RTBC, ePA and specialty pharmacy automation. They are particularly important opportunities for pharmaceutical companies—especially given the rapidly evolving niche markets for drugs and biologics to treat the growing number of patients with chronic diseases, which are expensive and require PA. Being involved is essential to having a voice at the table, understanding where opportunities lie and connecting with high-level, key decision makers.
Prepare for Deployment. Companies should be reviewing and updating their internal training materials. For Q4, these should be revised — or created — to address the evolving requirements of public and private payers and the use of RTBC information and ePA, as well as how they are being integrating into EHR work flows. Sales teams and others also should be brought up to speed on accelerating efforts to automate specialty pharmacy prescribing and dispensing.
Want to know more? Point-of-Care Partners is here to help with analyses, details on federal and state requirements, use of EHRs, strategic planning and much more. Drop me a line at email@example.com.
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